I am disappointed that the Minister, in his introduction of this Estimate, did not give us some more information as to the efficiency or economy that has resulted from the remarkable changes in the administration of national health insurance which have taken place within the last 18 months. Two very remarkable changes have taken place from which much might be expected: the abolition of the Insurance Commission on the one hand, with the bringing of the work of national health insurance administration directly into the Department itself; and secondly, the beginning of the establishment of the unification of the societies some months later. I think the House would like to hear the Minister's views, though they must be provisional at the moment, as to the economy and efficiency that have or have not resulted from those changes. We were given to understand in advance with regard to the unification of the societies that enormous economy would be effected and also that there would be greater efficiency in the carrying out of administration. In evidence submitted by the National Health Insurance Commission some years ago to a Committee of Inquiry it was stated that some 45 per cent. of the expense of the central administration would be saved. So far as we can learn from the Estimates there is as yet no economy whatever in the working of national health insurance. There is a slight increase in the expenditure of £2,703 net. Of course, I can understand that it is too soon to expect the major part of the economy that might be expected, but one would like to hear from the Minister whether he still holds that anything like the expectations of economy held out to us are likely to be verified by experience.
I should like particularly to draw the Minister's attention to the fact that whereas he has by the Act of last year made a very radical change in regard to the administration of national health insurance, he has as yet only touched the first part of the programme that he himself set before the Dáil and the country some years ago. It was in the year 1929, when the late Government introduced a Bill dealing with National Health Insurance, that the Minister moved a very important amendment which is to be found in Vol. 32, Parliamentary Debates, Col. 77:—
To delete all words after the word "that" and substitute therefor the words "declines to give a Second Reading to the National Health Insurance Bill, 1929, until proposals have been laid before the Dáil providing for—
(1) The administration of national health insurance through one society, and
(2) Medical benefit."
The Minister there set before himself, we understood, that when he was in a position of responsibility and power and able to carry out his programme there were two main reforms desirable in the system of National Health Insurance. One was carried out by the Act of last year; the other we have heard nothing about in recent years. I hope the Minister still regards that as a desirable and necessary reform if National Health Insurance is really to be a health insurance in more than name.
We have this system of what would be more properly called sickness insurance in this country for something over 20 years, but it has never as yet contained what is the essence of every health insurance scheme in other countries and what is the natural essence of any health insurance scheme, namely, provision for the care of the insured person himself; that is, his care as regards the prevention and treatment of sickness. Under our scheme we have no such provision. It has always been regarded by those who gave any study to the matter of health insurance in this or other countries that the scheme was thoroughly deficient in not having any such provision within its scope. The Minister was quite clearly of that opinion when in a position of less responsibility than now. We have, however, no reason to suppose that he has changed his mind. In his speech proposing the amendment I have read he summed up very carefully and methodically the evidence in favour of the establishment of a scheme of medical benefit. I would prefer to call it provision for treatment of the sick insured as the term "medical benefit" is likely to be misunderstood as meaning some method of giving such treatment on lines similar to those in vogue in Great Britain, a system which, in the opinion of those who have studied the problem as regards this country, would be unsuitable to this country. The Minister summarised and built up a complete case in favour of the establishment of some scheme of medical benefit. I hope that he still has that before him and that, while it may be necessary for him to proceed step by step, he is not going to draw back from the programme he laid down in 1929.
It is rather unfortunate that we in this country, among the more reputable civilised countries, are almost alone in this lack of provision for giving treatment to the sick insured. The whole of Ireland was without such a provision until late in 1929, when a scheme of medical benefit on the British lines was introduced in Northern Ireland. The definite reasons for its introduction are somewhat interesting. I should like to read a brief extract from a letter issued at that time by the Minister of Labour in Northern Ireland as to the reasons which led him to introduce this legislation. He stated:—
"In the first place, I should explain that Northern Ireland is being urged by the Imperial Government to enable them to ratify Conventions drawn up by the International Labour Offices at Geneva in 1927."
That is to say, that the reason why Northern Ireland adopted the scheme of medical benefit was, under compulsion, to attempt to put themselves in line with the more enlightened countries of the world. The letter went on to state:—
"These Conventions require the subscribing countries to provide medical benefit for workers, including agricultural workers, on an insurance basis, and have already been ratified, or are in process of ratification by 15 other countries, including Germany, France, Austria, CzechoSlovakia, Hungary, etc."
These are the only names given, although there must be eight or nine others. It appears, therefore, that in this almost essential social service the Irish Free State is one of the countries which is not in a position to ratify the Conventions drawn up by the International Labour Office in Geneva. It is, I think, unfortunate that we should have to confess that we do not make as good a provision for our insured workers as other countries, the names of some of which I have mentioned. I think it is particularly unfortunate that we should have to admit that in this particular social service we are lagging many years behind the neighbouring State of Northern Ireland. I quite realise that in some of our medical services the Irish Free State is in advance of the condition of things in Northern Ireland, but in this very essential part of national health insurance we are four and a half years behind them and we have no word from the Minister as to any advance in this direction.
In the evidence which the Minister gave the House in favour of a system of medical benefit, he was able to quote the advice of every Committee or Commission which ever studied the question—from the Report of a Committee as long ago as 1912-13; from the Report of the Irish Public Health Council in 1920; and, in certain terms, from the Report of the Committee of Inquiry on National Health Insurance appointed by the Minister for Finance of the late Government. It is true that that Committee was rather hesitating in its advice. It advised that such a system would be ideal, but, for "various reasons," which were unstated, it was unable to recommend that steps should be taken at the moment. That, however, was eight or nine years ago, and there has been time for many steps to have been taken since. Not only have no steps been taken, either by the last Government or the present Government, whose Minister is in favour of such a step, but there has been very little said about this natural development of National Health Insurance. The Minister was able to quote the deliberate opinion of the various Labour organisations in favour of a medical service for working people.
He might have said, if he had been aware of the fact, that that has been the policy urged on successive Governments by representatives of the medical profession for the last 25 years or longer. They have been unanimous for many years in the view that an adequate medical service could not be rendered to the working people of this country except by some medical service associated with the National Health Insurance Act. I have said that I do not want to stress the term "medical benefit" as it is misleading, but I would draw the attention of the Minister to the advice given by the Labour authorities, which he quoted here before, that the service ought to take the form of a National or a State Medical Service, and that it is the considered opinion of most people who have studied the question that the best service for insured persons and poor persons can be given by a combined National Medical Service which would undertake the duty both of attending to insured persons and attending to poor persons as is now done under the poor law dispensary service. The whole system of medical service would not, of course, end with attendance on the sick person in his house, but should include provision for hospital treatment and special arrangements. I do not want to delay the House by going into the details. I merely wish to indicate on broad lines the programme which the Minister himself had before him, and which I hope he will still keep before him. In his argument for a medical service on that occasion I think he was supported by his present colleague, then Deputy Lemass. I hope the Minister, in reply, will give us some expression of his opinion as to how the changes in the administration are working and are likely to work in future. Secondly, I hope he will hold out some hope of some further developments in the National Health Insurance system so as to make it a real live system in this country and not a system of money payments as it has been up to the present.
